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Diplopia NOTE CrackCast Show Notes – Diplopia – January 2020 www.canadiem.org/crackcast Chapter 18 – Diplopia NOTE: CONTENT CONTAINED IN THIS DOCUMENT IS TAKEN FROM ROSEN’S EMERGENCY MEDICINE 9th Ed. Italicized text is quoted directly from Rosen’s. Key Concepts: 1. Monocular diplopia persists in one affected eye, even when the other one is closed. It is an ophthalmologic problem related to refractory distortions in the light path or from buckling of the retina. 2. Binocular diplopia resolves when either eye is closed and is the result of misalignment in the visual axes. 3. Four lines of questioning that help formulate the differential diagnosis of binocular diplopia are as follows: (1) cadence of onset of symptoms (a sudden onset suggests an ischemic event; a fluctuation of symptoms suggests transient ischemic attacks, impending stroke, or neuromuscular disease); (2) directionality and orientation of diplopia (horizontal, vertical, torsional); (3) presence of pain, which suggests an inflammatory or infectious process, and (4) the presence of other associated symptoms, which suggest a larger disease process (eg, infection, CNS ischemia, neuromuscular disease) 4. The diagnostic approach to diplopia entails a methodical consideration of (1) a monocular (refractive) problem, which, when excluded, leads to consideration of (2) a simple restrictive, mechanical orbitopathy, which, when excluded, leads to consideration of (3) a palsy of one or more of the oculomotor cranial nerves, then (4) a more proximal neuraxial process involving the brainstem and related cranial nerves; if all else is excluded, then (5) a systemic neuromuscular process. 5. An isolated CN III palsy is associated with diplopia in all directions of gaze, except on lateral gaze to the affected side, and an eye that is deviated down and out, with a dilated pupil, and ptosis. Microvascular ischemia (typically seen in patients with diabetes), classically spares the pupil. A CN IV palsy results in a rotational diplopia that worsens on looking down and toward the nose. A CN VI palsy results in diplopia that worsens on lateral gaze toward the problematic side. 6. Simultaneous ipsilateral involvement of more than one of CN III, IV, or VI from a mass, inflammation, or infection in the posterior orbit or cavernous sinus (orbital complex syndrome) may cause a combination of palsies and is associated with retro-orbital pain or blurred vision due to venous congestion and possibly ipsilateral numbness or dysesthesia from involvement of the ophthalmic (V1) and maxillary (V2) trigeminal branches that travel through the orbital complex. 7. Diplopia from a neuraxial process involving the brainstem and related cranial nerves may present as (1) a focal lesion in the brainstem (eg. multiple sclerosis), (2) a more diffuse but still localized brainstem process (eg. brainstem tumor, lacunar stroke, CrackCast Show Notes – Diplopia – January 2020 www.canadiem.org/crackcast impending basilar artery thrombosis, vertebral artery dissection, or an ophthalmoplegic migraine), or (3) as part of a more diffuse neurologic syndrome involving the brainstem and oculomotor nerves (eg. infectious, autoimmune, neurotoxic, or metabolic process). 8. The diplopia in myasthenia gravis is associated with ptosis, gets worse as the patient fatigues, and improves with rest or on placing ice over the eye. 9. The empirical treatment of conditions causing diplopia, instituted even before testing for specific entities is begun, is directed toward imminent threats to airway and ventilation (eg. botulism and myasthenia gravis), immediate threats to CNS tissue viability (eg, with basilar artery thrombosis or stroke), and rapidly evolving threats to CNS tissue viability (eg. with meningoencephalitis or Wernicke’s encephalopathy). Rosen’s in Perspective Welcome back to another episode of CRACKCast. Today, we will spare you the typical introductory case as the content presented below is pretty dense. We will be reviewing a fairly common problem in today’s podcast - diplopia. Interestingly, diplopia can have a myriad of causes, and, when present, can be an indicator that something pretty serious is occurring in that patient. We will go about giving you a good way to conceptualize diplopia and teach you what you need to know to best interview, examine, and work up the next patient seeing double. So, sit back, take a sip of your coffee, and enjoy the ride! Core Questions: 1. What is diplopia and how is it classified? 2. What four questions help clinicians delineate the potential cause of a patient’s diplopia? 3. What are the cardinal directions of gaze and how are they tested? 4. Outline the physical exam for the patient with monocular and binocular diplopia. 5. Outline the DDx for monocular diplopia? 6. Outline the DDx for binocular diplopia? [Table 18.1] 7. Detail the different oculomotor palsies. [Figure 18.3] 8. Detail the various lacunar stroke syndromes. [Box 18.1] 9. Define internuclear ophthalmoplegia. 10. What ancillary tests are required for the patient presenting with diplopia? [Figure 18.4] Wisecracks: 1. What are the most common oculomotor palsies and what causes them? 2. What is orbital apex syndrome? 3. What is the “rule of the pupil” and how reliable is it? 4. Detail the physical exam maneuvers used to identify patients with myasthenia gravis. CrackCast Show Notes – Diplopia – January 2020 www.canadiem.org/crackcast Core Questions: [1] What is diplopia and how is it classified? Diplopia, the perception of double vision, is classified in many ways. However, Rosen’s breaks it down into two simple categories that will help you formulate your initial differential. It’s simple: Monocular Diplopia - Double vision that exists from dysfunction in one eye. Monocular diplopia persists even when the unaffected eye is closed. - Monocular diplopia is an ophthalmologic issue, resulting from distortions in the path of light through the eye or buckling of the retina itself. Binocular Diplopia - Double vision secondary to misalignment of the visual axes. Binocular diplopia abates when either eye is closed - Binocular diplopia can arise from several problems: - Mechanical orbitopathy - Cranial Nerve palsy - Proximal Neuraxial Process - Systemic neuromuscular process [2] What four questions help clinicians delineate the potential cause of a patient’s diplopia? The history in a patient with diplopia is profoundly important, and in some cases, will be all you need to make your diagnosis. During your next clinical interaction with a patient complaining of double vision, ask yourself and the patient the following: 1. What was the cadence of onset of symptoms? a. Rapid onset, often with maximal symptoms immediately, often points to an ischemic cause of the patient’s symptoms b. Fluctuating diplopia may point to transient ischemia or neuromuscular pathologies causing the patient’s symptoms 2. What is the directionality and orientation of diplopia and what aggravates it? a. Defined as either vertical, horizontal, or torsional 3. Is there any associated pain with diplopia? a. Points to potential inflammatory or infectious causes of the patient’s symptoms 4. Are there any systemic symptoms other than diplopia that are present? a. May lead you to a diagnosis of a systemic illness causing diplopia CrackCast Show Notes – Diplopia – January 2020 www.canadiem.org/crackcast [3] What are the cardinal directions of gaze and how are they tested? We are going to take you back in time to the clinical examination course in medical school for this question. There are six cardinal movements of gaze. Each cardinal direction marks the point at which the extraocular muscle and the nerve supplying it have their maximal effect. When visualizing it, think of a six-spoke asterisk or an “H” pattern. Each corner of the asterisk or “H” denotes one of the cardinal directions of gaze. The following table should help you think about it a bit better: Cardinal Direction of Gaze Extraocular Muscle Cranial Nerve Upper-Outer Gaze Superior Rectus III Upper-Inner Gaze Inferior Oblique III Temporal Gaze Lateral Rectus VI Nasal Gaze Medial Rectus III Lower-Inner Gaze Superior Oblique IV Lower-Outer Gaze Inferior Rectus III Now, we are humble practitioners of Emergency Medicine here on CRACKCast, so to simplify things, you can think about it this way: - Every extraocular movement is controlled by CN III (oculomotor nerve) EXCEPT for looking toward the temple (CN VI or the abducens nerve) or at the tip of the nose (CN IV or the trochlear nerve) [4] Outline the physical exam for the patient with monocular and binocular diplopia. So, let’s break it down. Here is our approach to the physical examination for the patient seeing double. Monocular Diplopia - Remember, this is exclusively a problem of the eye itself. So, you are going to do a thorough ophthalmologic examination including: - Visual acuity CrackCast Show Notes – Diplopia – January 2020 www.canadiem.org/crackcast - Cardinal directions of gaze - Peripheral field testing - Intraocular pressure testing - Pupillary examination - Direct response - Consensual response - Swinging light test - Fundoscopy - Slit Lamp Exam Binocular Diplopia - Now things get a little more complex, but if you think about the four mechanisms that cause binocular diplopia, things get a little easier - Remember, binocular diplopia can be caused by: - Mechanical orbitopathies - Cranial nerve palsies - Neuraxial lesions - Systemic processes - Knowing this, we here at CRACKCast recommend the following: - Detailing neurologic examination, evaluating - Cranial
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